The Irritable Heart of Soldiers and the Origins of Anglo-American Cardiology: The US Civil War (1861) to World War I (1918) (review)

During the American Civil War, Philadelphia physician Jacob Mendez Da Costa was puzzled by a peculiar cardiac disease causing disability among young soldiers: they complained of chest pain, palpitations, shortness of breath, incapacitating fatigue on the slightest exertion, and fainting spells. He dubbed the syndrome "irritable heart." Also identified by British army medical officers in the 1860s, the disease was recognized in various forms over the next several decades, only to reemerge as a major problem among British troops during World War I.

Cardiologist Charles Wooley has written an intriguing account of the men who studied this disease and their explanations for it. He highlights the importance of specialty hospitals in allowing for the sort of clinical research that made the development of cardiology as a field possible. Da Costa based his study in the cardiology ward of Turner's Lane Hospital in Philadelphia, the specialty hospital for Civil War soldiers better known for its much larger neurology wards. During World War I, military authorities established specialty hospitals for soldiers with cardiac disease in both the United States and England. Wooley describes the advances in cardiology that made careful study of these cases possible, such as the use of instruments (stethoscope, EKG, X ray), as well as advances in anatomy and physiology.

Interwoven throughout the account are a fascination with nosology, and a sensitive understanding of the adjectives "functional" and "organic" as applied to disease. Wooley recognizes that "functional" could be used in a limited sense to mean a disease of dysfunction—an irregular heartbeat, or an abrupt change in blood pressure. He also knows that the word has a broader connotation implying psychosomatic causes, or even malingering. Physicians tended to place irritable heart in the functional category, but the degree to which this was taken to imply mental weakness varied with different authors. William Osler, for example, tended to lump irritable heart with neurasthenia, noting how often palpitations and chest pain occurred in the neurotic female. Clifford Allbutt, on the other hand, who saw many cases at first hand in World War I, argued that "this group of symptoms is too uniform to be fictitious or fantastic" (p. 187). Throughout the history of this syndrome physicians struggled to shape proper clinical judgments in the face of an illness that appeared to cause significant symptoms, had few concrete signs, and could liberate a soldier from the army due to his disability.

Wooley wisely refrains from giving irritable heart a modern name, and instead reviews the range of diagnoses that probably contributed to the disease pool as identified by Da Costa and others. He notes that the disease appeared among men who had endured considerable stress, emotional and physical, as well as exposure to a broad range of infectious diseases. Many would have entered the army with hearts damaged by earlier rheumatic fever. Some probably suffered from supraventricular tachycardias, made worse by exposure to the stress of battle. Severe mitral valve prolapse probably contributed. Physicians noted that symptoms occurred after bouts of dysentery, and Wooley speculates that some of the irritable heart cases suffered from myocarditis caused by Coxsackie A and B viruses, common agents of diarrheal illnesses. Irritable heart was no one thing, but probably all these things, and more.

It is a common failing of authors to mention name after name in a narrative without properly identifying them or supplying context. In contrast, Wooley offers rich vignettes on the many researchers who pepper his story. At times these minibiographies detract from the main focus on irritable heart, as when he reproduces lengthy diary excerpts of humorous episodes involving motorcycles or social events...